Project helps hospitals cut down on colorectal SSIs

A project to reduce colorectal surgical site infections helped seven participating hospitals avoid a total of 135 SSIs and save $3.7 million over 2 1/2 years.

Under the direction of the Joint Commission Center for Transforming Healthcare and the American College of Surgeons, participating hospitals reduced superficial incisional SSIs by 45% and all types of colorectal SSIs by 32%. The average length of stay for hospital patients with any type of colorectal SSI decreased from an average of 15 days to 13 days. In comparison, patients with no SSIs had an average length of stay of eight days.

Colorectal surgery was identified as the focus of the project because SSIs are disproportionately higher among patients following colorectal surgeries, according to a Joint Commission news release. Colorectal surgery is a common procedure across different types of hospitals, can have significant complications, presents significant opportunities for improvement and has high variability in performance across hospitals.

The project addressed preadmission, preoperative, intraoperative, postoperative and post-discharge follow-up processes for all surgical patients undergoing emergency and elective colorectal surgery, with the exception of trauma and transplant patients and patients under age 18. Project participants studied the potential factors that contribute to all three types of colorectal SSIs: superficial incisional, deep incisional and organ space SSIs.

The project addressed the problem of colorectal SSIs using Robust Process Improvement methods. RPI is a fact-based, systematic and data-driven problem-solving methodology. Using RPI, project participants measure the magnitude of the problem, pinpoint contributing causes, develop specific solutions that are targeted to each cause and thoroughly test the solutions in real-life situations.

To reduce superficial incisional colorectal SSIs, participants took steps such as standardizing the preoperative instruction to patients and caregivers for applying the preoperative skin cleaning product, and establishing specific criteria for the correct management of specific types of wounds, which promotes healing and helps decrease the risk of developing SSIs.

To reduce all types of colorectal SSIs, participants took steps such as implementing warming interventions to ensure the patient’s temperature is consistently maintained at the recommended range for optimal wound healing and infection prevention, and implementing a weight-based antibiotic dosing protocol to address the inadequate administration of antibiotics.

The project used SSI outcomes data from ACS’s National Surgical Quality Improvement Program to guide the improvement effort. NSQIP data on outcomes of surgery are highly regarded by physicians as clinically valid, using detailed medical information on severity of illness and comorbidity to produce data on risk-adjusted outcomes, according to the Joint Commission news release. SSI is one of the most prevalent negative outcomes reported by NSQIP hospitals.

Over the course of the project, it became apparent that the “one-size-fits-all” approach in measuring and reducing the different levels of colorectal SSIs would not have the same success for all types of colorectal SSIs, especially organ space SSIs. These particularly challenging infections require more in-depth investigation, especially in surgical techniques and protocols, according to the Joint Commission news release. Further work is being conducted by pilot organizations to validate measurement tools to identify significant correlating factors that can be improved upon to reduce these more severe types of SSIs.